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Birthing a baby by the breech at home

Midwives' lack of experience and skill in facilitating the birth of a breech baby is not only letting women down, it is endangering them and their babies. Beverley Beech reports on a recent case brought to AIMS' attention.

At 28 weeks, one in five babies are in the breech position. Most babies turn spontaneously and, by the time the mother reaches term, only 3-4 per cent are in the breech position. Nevertheless, there are about 18,000 breech presentations at term annually in the UK.

In 1999, Canadian researchers led by Mary Hannah published the findings of a multicentre, international trial that compared caesarean section with vaginal 'birth' for a breech presentation at birth.[1] In April 2001, the Royal College of Obstetricians and Gynaecologists published Guideline No. 20 on the management of breech presentation. This document recommended that all women with an uncomplicated breech pregnancy at term (37-42 weeks) should be offered external cephalic version (manually turning the baby to a head-down position). The guideline went on to state that "the best method of delivering a term frank or compete breech singleton is by planned caesarean section".

One of the problems with the Hannah trial is that it did not compare vaginal breech birth, but vaginal delivery by obstetricians, and it has been comprehensively criticised by both lay and professional experts.[2],[3] Indeed, in discussions with obstetricians since the trial, it is clear that the majority of them have little or no understanding of the difference between a midwife-managed vaginal breech birth and an obstetrically managed vaginal breech delivery.

Women unwilling to be subjected to obstetric management (epidural, continuous electronic fetal monitoring, on their backs on a bed and vigorous manipulation of the baby as it emerges) now have considerable difficulty in finding skilled practitioners to assist them to in a breech birth. Many, as in the following case, are subjected to months of bullying and threats to force them to comply with the current edicts.

'Ann' had her first baby in Addenbrooke's Hospital and, as a result of that experience, she was determined to give birth to her second baby at home. When she was 28-weeks pregnant in June, she was informed that her baby was presenting by the breech and advised to deliver in hospital. After carefully considering the risks, Ann decided that to have her baby at home with a skilled midwife and declined the hospital's offer.

From June to August, she tried to get Jennifer Ferry, the Director of Midwifery and Supervisor of Midwives, to confirm that a skilled midwife would be available to attend the forthcoming birth. On 18 August, she received a letter from Ms Ferry, stating that she was 'unable to support a breech water birth at home'. Ann had intended using a pool for labour, but was open to guidance as to whether or not she would stay in the water for the birth. Ms Ferry pointed out that 'midwifery staff do not offer expertise in abnormal deliveries' and referred Ann to the Independent Midwives Association.

Ann could not afford an independent midwife and suggested that, if the Trust did not have midwives with the necessary skills, it should offer an independent midwife a contract. The Trust refused to do so.

When Ms Ferry failed to bully Ann into submission, she brought in Keith Day, the Administrative Director, who had no professional skills, to respond to Ann's attempts to obtain professional assistance.

Ann became increasingly desperate, anxious and alarmed at the possibility of going into labour and having no one with any skills to attend her. The local midwives who were likely to be on call were told by Ms Ferry that, if Ann called them out, they were to assess the situation and if the baby was presenting by the breech, they were to call an ambulance and take her into Addenbrooke's.

Eventually, Ann called AIMS is a state of much distress and anxiety. We lobbied Cathy McCormick at the Department of Health, Elayne Guest at the Local Supervising Authority and the Chief Executive of the Health Authority - none took any action to ensure that Addenbrooke's would respond to this woman's needs. In the meantime, Ann contacted three independent midwives herself. One would be away at the time of the birth and the other two were fully booked, but promised that if she went into labour and was still without a skilled midwife, then they would do their best to attend.

In the meantime, Jennifer Ferry, refused to train midwives to enable them to assist a breech birth or to offer an independent midwife a contract. It was clear that neither Ms Ferry nor anyone else in the Trust had any understanding of a midwife- managed breech birth compared with an obstetrically managed breech delivery.

On 5 September (seven days before the baby arrived), Keith Day wrote: 'Community midwives will attend [Ann] but they are not trained to provide unsupported assistance with a planned breech delivery at home. I can only reemphasise the point that the Trust is offering the services of these midwives, but I am most anxious that [Ann] clearly understands that the midwives in question can only act within their sphere of competence. Should the midwives be faced in the home with a situation that requires the input of clinical skills beyond their professional training, then [Ann] must accept the risks to which she has exposed herself and her unborn baby'.

Catch 22. Ann wanted a breech birth at home; the Trust would send midwives whom they had deliberately ensured were not trained to assist such a birth. If Ann went ahead with her plans, the Trust expected her to accept the consequences.

On 6 September, following a discussion with Ann, I responded to Mr Day's letter, describing the possible scenario should the Trust persist in their refusal to provide skilled midwifery care: '[Ann] goes into labour, the midwives arrive and advise her to go into hospital. She refuses and then you expect her to be attended by midwives whom you acknowledge do not have the skills to assist her. This cannot be considered an emergency because you have had plenty of warning that this will occur. The midwives, therefore, will be at risk of being reported to the UKCC for attending a woman without the necessary skills and having failed to obtain the necessary skills in good time.

'May I suggest an alternative scenario. [Ann] goes into labour. You contact an independent midwife who is skilled at attending a woman expecting a baby by the breech, and you also arrange for one of the community midwives to attend so that she learns these skills and is able to offer this service to other women asking for this type of birth in the future.

'The problem will not go away, and your Trust will find similar issues arising in the future, and you cannot rely on the independent midwives to bail you out of problems of your own making.

'Despite your Trust's vigorous suppression of home birth (your statistics are a disgrace when compared to an area like Torbay, where women have real choice and a 15 per cent home birth-rate), women will continue to birth at home and, occasionally, a baby will present unexpectedly by the breech. The midwives need to be trained to know what to do and, by failing to provide that training, your Trust is putting all women at risk.'

Mr Day replied: 'Once again, I would repeat my wish that [Ann] considers carefully the sound clinical advice she has been given in this matter and that her final decision will not prejudice a safe and happy outcome to this pregnancy.'

On 12 September 2000, Ann went into labour, having made no impression on the Trust whatsoever. In desperation, she rang two independent midwives, Jane Evans and Sally Stockley, both of whom dashed across the country to assist her. Jane Evans arrived first to find Ann on her hands and knees with a little pink foot protruding. Sally Stockley arrived shortly thereafter. Ann gave birth to an 11- lb baby, presenting by the footling breech and in a posterior position which spontaneously turned. Her daughter was born without a tear five minutes after the midwives arrived.

On 21 March 2001, Ann made a formal complaint to the UKCC, alleging that Jennifer Ferry had:

failed to ensure that midwives under her management and supervision were updated and supported to enable them to attend a breech birth, despite being given almost three months' notice that this might be required;

relinquished responsibility for advising on midwifery care to an unqualified administrator (Keith Day);

prepared to send midwives whom she acknowledged were not competent to attend a woman whom she knew had a baby presenting by the breech, thereby unnecessarily and willfully increasing the risk to Ann and her baby.

Attached to this complaint was a letter from Jane Swindells, a friend of Ann. In April 1993, she had been attended at home by midwives from Addenbrooke's. She wrote: 'The night Jacob was born, everything went really well until he began to emerge. It wasn't a head they saw but a bottom!!

'The midwives went "sheet white" (my husband's words) and told us we had to transfer in as they had no experience of delivering breeches! Knowing the baby was well and truly on his way out, I got as upside-down as I could and hoohooed and haa-haaed for all I was worth.

'On arrival in hospital, I was put flat on my back, legs in stirrups and given an episiotomy by a very 'gruff' obstetrician and out fell my baby. (and down fell my husband-he fainted). At the time, Jan and I were just relieved to have a 'live' baby and too overwhelmed to question the care we were given. The questioning set in a few days later and culminated two to three months later with a letter to the Trust, pointing out that:

the midwives had done all they could in the circumstances;

the Cambridge NHS midwives were very badly trained if they did not know how to assist an active breech birth;

there are many midwives in the UK (I named Mary Cronk) who were experienced in this kind of delivery, always with good outcomes; and

wasn't it about time they trained their community midwives properly?

'I at no time criticised my midwife or the care she had given as I felt she was as much a victim of a backward system as I was. The response was a curt thank-you-but-you-know-nothing type of letter. Seven years on, I am very sad to hear that nothing has moved ahead.'

On 13 December, the UKCC replied to Ann's complaint: 'The Preliminary Proceedings Committee gave careful consideration to the papers before it and decided to decline to proceed with the matter... The committee considers that there are no allegations of misconduct to be answered. It is the committee's view that the decisions taken were appropriate in the circumstances.'

So, that's alright then. The UKCC considered that it was acceptable to wash one's hands of an awkward woman and make no provision for her care-and that bullying women into accepting inappropriate care is acceptable, too. Thankfully, the UKCC was disbanded earlier this year and is now replaced by the Nursing and Midwifery Council. One hopes that they will have the interests of women and babies at heart, and will take seriously any future cases of bullying and intimidation brought to their attention.

Footnote:

Ann subsequently gave birth, at home, to her baby, a footling breech who weighed in at 11lbs.